Speakers: Larry Mauksch, MEd, Senior lecturer and licensed mental health counselor, UW Department of Family Medicine; and Berdi Safford, MD, Family Care Network.

Moderator: Judith Schafer, MPH, The MacColl Center for Health Care Innovation

Using a Patient-Centered Care Plan and Teamwork to Support Self-Management

8 Change Concepts for Practice Transformation

Tools for Your Team to Engage Patients in

Collaborative Care Plans

Larry Mauksch, MEd Senior Lecturer

Department of Family Medicine

University of Washington

Berdi Safford, MD Vice President and Medical Director for Quality

Family Care Network

Bellingham, Wash

Objectives

At the end of session, participants will be able to:

• 1. Explain skills and team designs to engage patients in goal setting and action planning.

• 2. Describe EHR tools and design features to efficiently engage patients in self-management.

• 3. Apply a team-training model to use in their sites of practice.

Workshop Outline Introduction and rationale

Time management

• Using the PCOF- agenda setting

A team approach to goal setting and action planning

• Video demonstration

Goal setting and action planning- practice

Team Training, EHR Design tips, and common pitfalls

Questions

Stages of Activation Hibbard et al Health Services Research 2007, 42(4) 1443-63

Level of activation (age 45 or older, 2.9 chronic conditions)

diabetes, HTN, lung, cholesterol, arthritis, heart

Percent

(cumulative)

May be overwhelmed and unprepared to

play an active role in their own health

12

May lack knowledge and confidence

about self management

29

(41)

Taking action but may lack confidence

and skill to support self management

37

(78)

Mastered self management but may not

maintain behaviors at times of stress

22

Primary Care Realities

Primary Care patients average 3-6 problems per visit

Indigent primary care populations have a greater illness burden

Half of adults have two or more chronic illnesses

•75% of US health care dollars go to care for chronic illness

Time Demands in Primary Care Am J Public Health. 2003;93:635–64; Ann Fam Med 2005;3:209-214.

2500 patients

Conservative time estimates

Ten most common

Chronic illnesses

Well controlled

3.5 hrs/day

Poorly controlled

10.5 hrs/day

Preventive care

Level A and B recommendations

7.4 Hours per day

“Primary Care is a

team sport.”

Bruce Bagley, MD, Medical Director of Quality, American

Academy of Family Physicians

Teamwork for what?

To manage time

To support self management

Relationship Communication and Efficiency Mauksch et al, July 14 2008, Arch of Intern Med

Ongoing influence

Rapport and Relationship

Mindfulness

Topic Tracking

Empathic response to

cues

Sequential

1. Upfront collaborative

agenda setting

2. Hypothesis testing and

understanding the patient perspective

3. Co-creating

a plan

SMS: problem solving

Visit Organization

Agenda collision

Acute

Chronic HM /

Preventive

SMS

Agenda Creation

Avoid premature diving by patient or yourself

When needed interrupt the patient or yourself:

Acknowledge, Empathize

Share reasoning

If the list is greater than three items,

the patient is screen positive for depression or anxiety

Ask, “what is most important”

• Listen (feel) for the most important concern

• Introduce self management if time allows and appropriate

Orient the patient:

“I know you are here to talk about ____. Before we get into_____ is there something else important to addresses today? Making a list will help us

make the best use of time”.

Upfront Collaborative Agenda Setting Brock, Mauksch, et al. JGIM, Nov, 2011; Mauksch et al, Fam, Syst, Health, 2001

Identifies patient’s priorities

Organizes the visit

Decreases chance that patients or providers will introduce “oh by the way” items

Screens for mental disorders

Facilitates shared decisions about time use between acute, chronic, health maintenance care, including self management support

Does not lengthen the visit; protects time for planning

Decreases clinician anxiety

Observation Form Purpose and

Training

The value

• Structures vision

• Creates and standardizes vocabulary

Primarily for formative assessment and to strengthen the “observer self” (mindfulness)

Online training:

http://uwfamilymedicine.org/pcof

PCOF Use Behavior in either of the columns to the right of

thick vertical line is in the competent range

Observers mark accurately and avoid giving the benefit of the doubt

Feedback is best:

When solicited

Specific, rather than

general

Curious, not judgmental

Self-management Principles of

PCMH

Respect patient and family values

Encourage patients to expand their role in caring for their health

Communicate with patients in a culturally appropriate manner

that the patient understands

Provide support at every visit through goal setting and action planning

Self-management Support

“Education is not the filling of a pail, but the lighting of a fire.”

•-- William Butler Yeats

Self-management Support

Remove guilt

No more “noncompliant” patients

• “if a patient does not do something you recommend, there is always a reason” --quote from a surgeon

Enjoy your Practice

Be a coach – this is the patient’s chronic condition

Dance not wrestle

Collaborative Goal-

setting

Offer a variety of choices

Listen to what the patient wants

Go with the patient’s choice

Just ONE goal at a time

Behavior Change and

Goal Setting

Provider

Determined

Patient Determined

Goal Disease Can be from a larger

domain

Pros Helps with disease

management

Builds patient

investment

Cons Greater resistance

(contemplation)

Requires more

patience, may not

be disease focused

at first

Patient Centered Problem Solving

What can help increase confidence?

Confidence- 1(low) to 10(high)

Barriers?

When?

How often?

Focus the activity (biking)

Name an activity (exercise)

Brainstorm activities (different ways)

Name the goal (wt loss)

Meet the patient where s/he is and hone

Assist with Action Planning

Things I can do to help reach this goal:

a.

b.

c.

d.

Action Planning

• What I will do:

• How often?

• When?

• Potential barriers?

• How will I overcome these barriers?

My Ongoing Action Steps

Confidence Ruler

1 2 3 4 5 6 7 8 9 10

Not Somewhat Very

Confident Confident Confident

Increase Confidence

What would it take to make your confidence a ____?

•(1 higher than their current rating)

Arrange follow-up

Would it be OK if Christine calls you next week to see how this is going?

Video 1

Video 2

PCCP Chart review Chunchu, Mauksch, et al. Fam, Syst, Health, 2012, September

PCCP

51 yrs; 60%F

Controls

55 yrs; 40% F

Goal documented 96 % 43 %

Ongoing activity 89 34

Specific activity 78 41

How often 68 07

When 68 07

Barriers 75 01

Confidence 71 00

What can help with confidence 53 00

Pick something to change in

your life

One person counsels

0ne is the patient

Focus on a simple, real issue

Patient: Be ambitious

Counselor: restrain for success

Each person plays patient and

clinician

Patient Centered Problem Solving

What can help increase confidence?

Confidence- 1(low) to 10(high)

Barriers?

When?

How often?

Focus the activity (biking)

Name an activity (exercise)

Brainstorm activities (different ways)

Name the goal (wt loss)

Meet the patient where s/he is and hone

Work Flow Options

MA establishes goal and plan

MA establishes goal, part of plan, PCP finishes

MA establishes goal, PCP completes plan

PCP establishes goal and completes plan

MA integrates progress check into agenda setting at subsequent visits or on the phone

For any patient who is working on

self management

Weave it into the discussion

•Most patients with chronic illnesses

•Patients with whom you discuss health risk behaviors, eg, diet, alcohol, exercise

•Patients who need help with simple behavior changes, eg., remembering to take Rx

Team Design Reflections

Team expansion is needed for ambivalent or pre-contemplative patients

•Nurse

•Care manager

•Behavioral health

•Extra medical assistant with extra training

Physicians need extra training for complex patients and close relationship with care manager functionality

TEAM TRAINING

SKILL LEARNING TO IMPROVE PATIENT CARE AND TEAM WORK

Larry Mauksch, M.Ed University of Washington Department of Family Medicine

TEAM COMMUNICATION TRAINING

Team members reinforce use of communication

skills in one another

Shared learning of skills builds

team function

Training Model

Introduction to Skills Demonstration and practice

Teamlet members observe each

other using extended

appointment slots

Groups meet to share learning and set goals

• Within teamlets

• Across teamlets

Recurrent observations and team meetings for

reinforcement

Do the cycle again to learn more skills and achieve more

goals

Mauksch L. Improving Patient Centered Communication:

A team development model.

Medical Home Digest. 2011(January-April):7-14.

http://www.safetynetmedicalhome.org/sites/default/files/Medical-Home-Digest-April-2011.pdf.

Patient Template: Teamlet training

9:40 MA gets next patent and repeat cycle two more times

9:30 to 9:40 debrief encounter

8:45 -9:30

8:45 to 9:00 MA interview patient and MD observes

9:00 to 9:30 MD interviews patient and MA observes

8:40-8:45 MA bring patient to exam room and explains teamlet training- at some point is joined by MD, ARNP or PA

8:30-8;40 discuss needs of first three patients

New applications of the EMR

Facilitates Team Communication to:

Organize care with action planning Reinforce, refine and celebrate

Team member training

Reminds the team member about core ingredients

Patient Engagement

(the patient – team member – screen triangle)

The patient and provider collaboratively problem solve

Capture each team member’s

contribution

Work into the existing workflow

Be able to generate a

printable action plan for the patient

Be easily visible when first entering

the chart

Larry Mauksch, M.Ed University of Washington Department of Family Medicine

EHR Design Modification Ideas

The PCCP should be easily visible when first entering the chart

Supports efficient workflow

• Minimal clicks to move through the chart

• Related sections auto populate one another

• Easy print function.

Easy way to revise the action plan to note progress, revise or create new goals

Part or all of PCCP available to patient via portal or via an APP

References Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med. Sep-Oct

2007;5(5):457-461.

Brock DM, Mauksch LB, Witteborn S, Hummel J, Nagasawa P, Robins LS. Effectiveness of intensive physician training in upfront agenda setting. J Gen Intern Med. Nov 2011;26(11):1317-1323.

Chunchu K, Mauksch L, Charles C, Ross V, Pauwels J. A Patient Centered Care Plan in the EHR: Improving Collaboration and Engagement. Families, Systems, and Health. 2012;30(3):199-209.

Epstein RM, Mauksch L, Carroll J, Jaen CR. Have you really addressed your patient's concerns? Fam Pract Manag. Mar 2008;15(3):35-40.

Mauksch L. Improving Patient Centered Communication: A team development model. Medical Home Digest. 2011(January-April):7-14. http://www.safetynetmedicalhome.org/sites/default/files/Medical-Home-Digest-April-2011.pdf. Accessed May 31, 2012.

Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med. Jul 14 2008;168(13):1387-1395.

Safford BH, Manning C. Six characteristics of effective practice teams. Fam Pract Manag. May-Jun 2012;19(3):26-30.

Schumann K, Sutherland J, Majid H, Hill-Briggs F. Evidence-Based Behavioral Treatments for Diabetes: Problem-Solving Therapy. Diabetes Spectrum. 2011;24(2):64-69.

Q & A

Using a Patient-Centered Care Plan and Teamwork to Support Self-Management

Project Funders

We would like to thank the following for the generous support:

The Commonwealth Fund (Project Sponsor)

Co-Funders:

Colorado Health Foundation

Jewish Healthcare Foundation

Northwest Health Foundation

Partners HealthCare

The Boston Foundation

Blue Cross Blue Shield of Massachusetts Foundation

Blue Cross of Idaho Foundation For Health

Beth Israel Deaconess Medical Center

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http://www.surveymonkey.com/s/KSHNXSP

Using a Patient-Centered Care Plan and Teamwork to Support Self-Management